text:
- CTC should NOT be approved.
- There are multiple published studies indicating that it is an INFERIOR test compared to visual colonoscopy - it has missed polyps and it has missed colon cancers also when compared to visual colonoscopy.
- The only studies that show some benefit were done at "expert" centers by "ctc experts" and hence that level of performance will not be duplicated by all radiologists
- also the plan to "monitor" small polyps found on ctc as proposed by the radiology societies is simply bordering on malpractice as there is clear evidence that even small polyps can have cancer on pathology evaluation when removed and evaluated under microscope.
- the patient also has to undergo colon preparation prior to ctc also just like in visual colonoscopy and ctc is done with no sedation hence the patient is in more discomfort
-if a polyp is found on ctc then the patient and insurance company will have to incur ADDITIONAL EXPENSE and inconvenience to undergo regular visual colonoscopy to remove the polyp and that will likely be on a different day and hence after another colon prep. Wheras with visual colonoscopy the polyps are all removed out at the same time as the test.
-the screening ctc repeat interval duration is also shorter at 5 years and hence there is additional expense in doing more tests.
- it is yet unknown to what extent the body will be harmed by the massive doses of radiation during a ct scan - the radiation is multiple times that of any plain xray - hence to expose a patient to unecessary radiation is not good as visual colonoscopy can be done without any radiation exposure.
- any new test should be approved only if there is clear benefit over existing tests and in this case ctc clearly has NO additional benefit over visual colonoscopy.
I would strongly urge Medicare to initiate reimbursement for CT colonography. Results of the national multicenter CTC trial (ACRIN 6664) have shown that this an effective screening tool. Adding an effective screening tool only improves our chances of preventing colon cancer, and its associated morbidity and mortality. As with all disease, early prevention is critical and ultimately cost effective.
To whom it may concern,
As a fellow in gastroenterology, I have used CTC in the evaluation of patients who have failed or difficult colonoscopies for a variety of indications and have found it useful. I also think it is an excellent tool for cancer detection (visualizing lesions that have already become advanced cancers). But I have been following the literature closely and have several reservations about the use of CTC in cancer prevention which is one of the goals of a colorectal cancer screening program. Cancer prevention relies on the ability to detect pre-cancerous lesions or "polyps." A well-publicized study by Soetikno and colleagues described the high malignant potential of flat polyps that by definition cannot be detected by CT (and are difficult even to see during colonoscopy). This study should be repeated and verified in other populations before the jury decides on flat polyps. In addition to flat polyps there is the issue of small polyps. Radiologists recognize the limited ability to detect lesions less than 6mm, and have agreed not to disclose these smaller polyps to patients and their providers even when these lesions are visualized! Aside from ethical concerns of this lack of disclosure, I feel that this diminishes the prevention aspect of screening. Interestingly, in less well-publicized research in Clinical Gastroenterology Hepatology, Gupta and colleagues showed that radiologist often underestimate the size of the polyps that they seen, which means that even larger polyps may go unreported and undetected. Finally, many of the large CTC studies cull out super-expert readers even from among groups of expert radiologists. I believe in the ACRIN study (the results to be released in December)...the investigators excluded 2 board certified radiologist because of poor performance on a reading exam; these results are therefore not generalizable to the abilities of the radiology community. Finally, CT scans, unlike MRIs and ultrasound, subject people to ionizing radiation. Repeated exposure (every 5 years) to radiation, would undoubtably increase cancer risk.
In summary, with rapidly improving technology in the area of imaging, capsule tests, etc, I am confident that we will soon find a screening test for colorectal cancer that is noninvasive and accomplishes the goal of cancer prevention and detection without exposing patients to immeasurable risks like radiation. I look forward to the day when I can offer this type of test to my patients. I think adopting CTC as a screening test at this point is premature.
Thank you kindly for allowing me to submit my opinion.
Jaya Agrawal
CTC should NOT be approved as a standard screening test for colorectal cancer. This is an appropriate test for patients who have failed conventional colonoscopy, and it should be approved in those settings but it must not be widely applied to the general public as a frontline screening option due to extensive CT associated radiation simply for ''screening'' and the fact that any lesions found cannot be removed even after so much radiation exposure any the person would again need a second colonoscopy for this. Lastly the test is not as good as a conventional colonoscopy and many polyps may be missed giving a false sense of security!
To Whom It May Concern:
I fully support virtual colonoscopy. According to what I have read, Virtual Colonoscopy has been clinically proven to be as effective as optical colonoscopy, the current gold standard, in several major studies. Virtual colonoscopy, being minimally invasive, drastically improves the chances that the majority of the recommended screening population (i.e. 50 years and older) will actually be screened for cancer, unlike the current estimates between 15-40% currently being screened with other procedures. Since virtual colonoscopy has been proven to be as effective, I believe Medicare and Medicaid patients should have the opportunity to use virtual colonoscopy as a screening choice.
The following are a list of some studies I base my opinion on:
The New England Journal of Medicine "CT Colonography versus Colonoscopy for the Detection of Advanced Neoplasia", David H. Kim, M.D., Perry J. Pickhardt, M.D., Andrew J. Taylor, M.D., Winifred K. Leung, M.D., Thomas C. Winter, M.D., J. Louis Hinshaw, M.D., Deepak V. Gopal, M.D., Mark Reichelderfer, M.D., Richard H. Hsu, M.D., and Patrick R. Pfau, M.D., October 4, 2007, (Vol. 357, No. 14)
"Computed Tomographic Virtual Colonsocopy to Screen for Colorectal neoplasia in Asymptomoatic Adults", Perry J. Pickhardt, M.D., J. Richard Choi, Sc.D., M.D., Inku Hwang, M.D., James A. Butler, M.D., Michael L. Puckett, M.D., Hans A. Hildebrandt, M.D., Roy K. Wong, M.D., Pamela A. Nugent, M.D., Pauline A. Mysliwiec, M.D., M.P.H., and William R. Schindler, D.O., December 2003 issue (Vol. 349, No. 23)
American Gastroenterological Association "AGA Supports New Guidelines Favoring Tests That Prevent Colorectal Cancer ", March 5, 2008
Alimentary Pharmacology & Therapeutics "Virtual vs. optical colonoscopy in symptomatic gastroenterology out-patients: the case for virtual imaging followed by targeted diagnostic or therapeutic colonoscopy", M.Bose, J.Bell, L.Jackson, P.Casey, J.Saunders, O.Epstein Volume 26 Issue 5 Page 727-736, September 2007
American Cancer Society "Prevention the Focus of New Colon Cancer Screening Guidelines", Article date: 2008/03/05
"Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology", Bernard Levin, MD, David A. Lieberman, MD, Beth McFarland, MD, Robert A. Smith, PhD, Durado Brooks, MD, MPH, Kimberly S. Andrews, Chiranjeev Dash, MD, MPH, Francis M. Giardiello, MD, Seth Glick, MD, Theodore R. Levin, MD, Perry Pickhardt, MD, Douglas K. Rex, MD, Alan Thorson, MD, Sidney J. Winawer, MD and for the American Cancer Society Colorectal Cancer Advisory Group, the US Multi-Society Task Force, and the American College of Radiology
American Journal of Roentgenology " Primary 2D Versus Primary 3D Polyp Detection at Screening CT Colonography", Perry J. Pickhardt, Andrew D. Lee, Andrew J. Taylor, Steven J. Michel, Thomas C. Winter, Anthony Shadid, Ryan J. Meiners, Peter J. Chase, J. Louis Hinshaw, John G. Williams, Tyler M. Prout, S. Hamid Husain, David H. Kim, 189, December 2007
"Translucency Rendering in 3D Endoluminal CT Colonography: A Useful Tool for Increasing Polyp Specificity and Decreasing Interpretation Time", P. J. Pickhardt August 2004 AJR:183(2),429 - 436
"Three-Dimensional Endoluminal CT Colonography (Virtual Colonoscopy): Comparison on Three Commerically Available Systems", P. J. Pickhardt December 4, 2003 AJR: 181, 1599-1606
"Electronic Cleansing and Stool Tagging in CT Colonography: Advantages and Pitfalls with Primary Three Dimensional Evaluation", Perry J. Pickhardt, September 2003:181, 799-805
Annals of Internal Medicine "Location of Adenomas Missed by Optical Colonoscopy", Perry J. Pickhardt, MD; Pamela A. Nugent, MD; Pauline A. Mysliweic, MD, MPH; J. Richard Choi, ScD, MD; and William R. Schnindler, DO, September 7, 2004 | Volume 141 Issue 5| Pages 352-359
Archives of Internal Medicine "Computed Tomographic Colonography to Screen for Colorectal Cancer, Extracolonic Cancer, and Aortic Aneurysm", Model Simulation With Cost-effectiveness Analysis Cesare Hassan, MD; Perry Pickhardt, MD; Andrea Laghi, MD; Daniel Kim, MD; Angelo Zullo, MD; Franco Iafrate, MD; Lorenzo Di Giulio, MD; Sergio Morini, MD Arch Intern Med. 2008;168(7):696-705.
Gastroenterology "Standards for Gastroenterologists for Performing and Interpreting Diagnostic Computed Tomographic Colonography", Don C. Rockey, Matthew Barish, Joel V. Brill, Brooks D. Cash, Joel G. Fletcher, Prateer Sharma, Sachin Wani, Maurits J. Wiersema, Laura E. Peterson, and Jennifer Conte, 2007;133:1005-10242-158
"Surface Visualization at 3D Endoluminal CT Colonography: Degree of Coverage and Implications for Polyp Detection", Perry J. Pickhardt, MD; Andrew J. Taylor, and Deepak V. Gopal, 2006 | 130: 1582-1587
"Computed Tomographic Virtual Colonoscopy Computer-Aided-Polyp-Detection in Screening", Ronald M. Summers, Jianhua Yao, Perry J. Pickhardt, Marek Franaszek, Ingmar Bitter, Daniel Brickman, Vamsi Krisna, and J. Richard Choi, 2005 | 129: 1832-1844
"Position of the American Gastroenterological Association (AGA) Institute on Computed Tomographic Colonography", 2006 | 131: 1627-1628
Radiology "Screening for Colorectal Neoplasia with CT Colongraphy: Initial Experience from the 1st Year of Coverage by Third-Party Payers", Perry J. Pickhardt, MD, Andrew J. Taylor, MD, David H. Kim, MD, Mark Reicheldferfer, MD, Deepak V. Gopal, MD, and Patrick R. Pfau, MD, 2006. 0:2412052007
"Linear Polyp Measurement at CT Colonography: In Vitro and in Vivo Comparison of Two-Dimensional and Three-dimensional Displays", Perry J. Pickhardt, MD, Andrew D. Lee, MD, Elizabeth G. McFarland, MD, Andrew J. Taylor, MD, 2005; 236:872-878
"Building a CT Colonography Program: Necessary Ingredients for Reimbursement and Clinical Success", Perry J. Pickhardt, MD,Andrew J. Taylor, MD, Gary L. Johnson, MD, Lawrence A. Fleming, MD, Debra A. Jones, MD, Patrick R. Pfau, MD, Mark Reichelderfer, MD, 2005; 235:17-20
"Incidence of Colonic Perforation at CT Colonography: Review of Existing Data and Implications for Screening of Asymptomatic Adults", Perry J. Pickhardt, MD, 2006; 239: 313-316
I am sure there are other studies and data available. I hope you take all of this into consideration when making your final decision. I believe you will reach the same conclusion: virtual colonoscopy, in many cases, is equivalent to or more effective than some currently reimbursed procedures such as flexible sigmoidoscopy, fecal blood occult screening and barium enemas. Thank you for your consideration.
Yours truly,
Garrett Karl Andersen, M.D.
June 18, 2008
Re: NCA Tracking Sheet for Screening Computed Tomography Colonography (CTC) for Colorectal Cancer (CAG-00396N)
Dear Mr. Larson:
The Association of Community Cancer Centers (ACCC) appreciates that the Centers for Medicare and Medicaid Services (CMS) has initiated a national coverage analysis (NCA) for computed tomography colonography (CTC), also referred to as virtual colonoscopy.1 ACCC agrees with the March 5, 2008 cancer screening guidelines developed by the American Cancer Society (ACS), the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology recommending CTC as a prescribing option for colon cancer screening and urges CMS to provide this option to Medicare beneficiaries.
ACCC is a membership organization whose members include hospitals, physicians, nurses, social workers, and oncology team members who care for millions of patients and families fighting cancer. ACCC's more than 700 member institutions and organizations treat 45% of all U.S. cancer patients. Combined with our physician membership, ACCC represents the facilities and providers responsible for treating over 60% of all U.S. cancer patients. We often are at the front line in preventing and fighting cancer and therefore look forward to working with CMS to increase the available options of life-saving cancer screening tests for Medicare beneficiaries, such as virtual colonoscopy.
ACCC applauds CMS for taking the initiative to cover this valuable technology. Our members painfully understand the grim statistics regarding the poor utilization of colorectal screening tests by Medicare beneficiaries. According to the American Cancer Society (ACS), more than 148,000 new cases will be diagnosed and more than 49,000 people will die from colorectal cancer in 2008.2 Unfortunately, by failing to have a colorectal screening test early, many Medicare beneficiaries learn that they have the disease at its later stages, making it harder for us to treat and for our patients to survive. We welcome the opportunity to have more choices to detect this disease at its earlier stages.
As stated above, the Tracking Sheet references recently published guidelines that recommend CTC as a screening test for colorectal cancer. These guidelines were issued jointly by the American Cancer Society (ACS), the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology and are an update to current recommendations.3 ACCC believes that the updated guidelines provide an accurate and fair assessment of the clinical benefits and practical shortcomings of CTC. Specifically, virtual colonoscopy requires less time to administer, provides better imaging of the colon and other organs, and is minimally invasive for the patient. As an added benefit, CTC does not require the patient to be anesthetized or stay in the hospital or surgical center for a significant period of time. Although the preparation protocol is similar to other screening tests and equally uncomfortable, we urge CMS to cover CTC because this will provide physicians and their patients with another screening option.
In our fight against cancer, we often work with Congress to develop policies to encourage appropriate access to a variety of screening tests for and treatments of cancer. One such example occurred with the passage of the Balanced Budget Act of 1997 (BBA). Within the BBA, Congress required CMS to cover certain colorectal screening tests and provided CMS with the flexibility to cover new technologies in the future.4 ACCC believes that by including the CTC as a covered benefit, CMS will further Congressional intent to provide Medicare beneficiaries with a variety of colorectal cancer screening options.
Our physicians rely on clinical guidelines and scientific journals to remain current in our fight against cancer. We believe that the updated guidelines recently issued are scientifically accurate and fairly portray the current state-of-theart care relating to screening for colorectal cancer. The guidelines detail previous and ongoing studies related to CTC, including the preliminary findings of the American College of Radiology Imaging Network #6664 study (ACRIN). This study followed approximately 2,500 patients across 15 institutions. Initial findings demonstrated that CTC had a sensitivity of 90 percent for adenomatous colorectal lesions of 1 cm or larger.5 The guidelines further describe other ongoing studies, and we urge CMS to review the findings of those studies and the ACRIN trial once completed.
ACCC greatly appreciates the efforts of CMS and hopes that by adding CTC as a Medicare covered screening test for colorectal cancer more beneficiaries will be screened. By detecting the disease earlier, we hope to save more lives. We look forward to working with CMS to implement this valuable Medicare benefit and would be pleased to answer any questions regarding these comments. Please contact me at 301-984-9496 ext. 221 if ACCC can be of any assistance as CMS continues to evaluate the coverage of screening CTC.
cc: Joseph Chin, MD Steve Phurough, MD
As Chair of Radiology at the University of California, San Francisco I am submitting my opinion that CT Colonography for colorectal carcinoma screening should be fully covered by CMS. CTC has evolved to become a test that is now shown by multiple large prospective trials to be as effective as colonoscopy for the detection of clinically significant polyps. The released results of the ACRIN 6664 National CTC Trial which is the largest prospective trial to date in a screening asymptomatic patient population demonstrates 90% per patient sensitivity and 86% specificity for large (10 mm or larger) colorectal neoplasia. The goal of CTC is to detect these significant precursor lesions and to prevent the development of cancer. The recently published joint collaborative guidelines from ACS (Americna Cancer Society) , USMSTF (United States MultiSociety Task Force) and ACR (Amercian College of Radiology) clearly shows that major organizations endorse CTC as a valuable test for colorectal cancer screening. In fact for the first time it is stated that tests that detect adenomatous polyps and cancer are preferred indicating decreased preference for FOBT (fecal occult blood test) and FIT (fecal immunochemical test). Note that FOBT is currently covered. Advantages of CTC include the lack of need for sedation, the relative ease of the test on the patient and a lower complication rate (including perforations). This test is ready to play a role in screening for colorectal carcinoma in this country. I strongly support approval of national coverage of screening CTC by CMS.
1.Kim DH, Pickhardt PJ, Taylor AJ, et al. CT colonography versus colonoscopy for the detection of advanced neoplasia. N Engl J Med. 2007;357:1403-1412
2.Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis: computed tomographic colonography. Ann Intern Med 2005; 142:635-650
3.Pickhardt PJ, Choi JR, Hwang I, et al. CT virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003;349:2191-2200
4.Yee J, Akerkar GA, Hung RK, Steinauer-Gebauer AM, Wall SD, McQuaid KR. Colorectal neoplasia: performance characteristics of CT colonography for detection in 300 patients. Radiology 2001; 219:685-692
5. Levin B, Lieberman DA, McFarland B, et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008; 58:130-160.
C3: Colorectal Cancer Coalition's Comments Regarding National Coverage Analysis for CT-Colonography These comments are submitted on behalf of C3: Colorectal Cancer Coalition (C3), a non-profit, nonpartisan advocacy organization that is committed to the fight against colon and rectal cancer. We appreciate the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) National Coverage Analysis (NCA) on Computed Tomography Colonography (CTC). C3 pushes for research to improve screening, diagnosis, and treatment of colorectal cancer; for policy decisions that make the most effective colorectal cancer prevention and treatment available to all; and for increased awareness that colorectal cancer is preventable, treatable, and beatable.
The American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology issued revised guidelines for colorectal cancer screening in March 2008 . Their rigorous, evidence-based evaluation of the various screening methods resulted in the addition of CTC to the screening guidelines.
We believe that all Americans should have full access to credible colorectal cancer screening. Thus, C3 fully supports the coverage of CTC by Medicare.
Colorectal cancer is the third most commonly diagnosed cancer and the second most common cause of cancer death in the United States. This disease claims the lives of nearly 50,000 men and women annually. When it is diagnosed at an early stage, the 5 year survival rate is nearly 90 percent. However, when cancer is not diagnosed until it has spread to distant organs, the 5 year survival rate is only 5 percent. In addition, when precancerous polyps are discovered and removed, colorectal cancer can not only be detected early, it can be prevented. Since 90 percent of colorectal cancer diagnosis occurs after the age of 50 and the risk of developing colorectal cancer increases with each decade of life, routine screening for colorectal cancer is critical for Medicare's consumers. Despite the passage of the Balanced Budget Act (BBA) of 1997, which authorized coverage for colorectal cancer screenings for Medicare recipients, colorectal cancer screenings are still very much under-used. The Centers for Disease Control and Prevention (CDC) estimates that as many 60 percent of deaths could be prevented if everyone age 50 and older were screened regularly . One of the barriers to screening is patient concern about an invasive procedure such as colonoscopy and flexible sigmoidoscopy. CT colonography (CTC) uses x-rays to produce two- and three-dimensional images of the colon. The exam takes around ten minutes, does not require a sedative, and is less expensive than optical colonoscopy. CTC is not invasive, and its sensitivity and specificity are acceptably high. From a patient's perspective, these characteristics make CTC an attractive option. Thus, we feel that reimbursement of screening CTC by Medicare may increase screening rates by Medicare consumers.
Recommendations: 1. Medicare should provide coverage for CTC that is consistent with all colorectal cancer screening tests recommended by the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Their recommendation includes tests such as fecal occult blood tests (FOBTs), barium enemas, flexible sigmoidoscopy and colonoscopy, which are already covered under Medicare.
2. Medicare should base payment for screening CTC on that for diagnostic CTC, which is already billable under several local coverage determinations under Medicare. A diagnostic CTC can be ordered in some Medicare areas when symptoms or signs of the disease are determined to be present by a physician. Screening CTC is appropriate when individuals have no signs orsymptoms of colorectal cancer.
3. CTC should be exempt from cuts to imaging services reimbursement under Medicare imposed by the Deficit Reduction Act (DRA) of 2006. C3 thanks you for the opportunity to comment on this national coverage analysis and appreciates your willingness to hear from patients and advocates who would be impacted by any future national coverage determination.
CTC for many different reasons in the correct setting is a very valuable tool for screening and surveillance and should be utilized. In my particular case I have an "impossible" colon to navigate and am at high risk and it would be medically useful to CTC. am a retired GI doctor and former Clinical Associate Professor Medicine and in manyh cases I was frustrated in myh practice to offer CTC, sometimes as first choice.
I strongly urge CMS to initiate national coverage for Virtual Colonoscopy (VC). However, I believe that the only appropriate way to provide VC is in the setting of a comprehensive colorectal cancer screening process, i.e., VC with the opportunity for a same-day, same-prep therapeutic colonoscopy (polypectomy) for those with discovered polyps.
VC is now a proven screening test based on numerous regional and national randomized controlled trials, including ACRIN 6664. Further, VC is clearly more effective than three of the four covered CRC screening tests (FOBT, Flexible Sigmoidoscopy, and Barium Enema), and is as effective as Screening Colonoscopy. [There is a tendency to think of colonoscopy as the perfect "gold standard" test when in actuality it is only 90% sensitive in detecting significant polyps. With new technologies and reading techniques, VC at least matches this sensitivity, and may soon exceed it. For example, the VC studies demonstrate numerous polyps and cancers that were detected on VC, but missed on colonoscopy.]
However, the major problem with VC is the lack of therapeutic options when polyps are discovered. In the setting of stand-alone VC, these patients will very likely be forced to make an appointment with a colonoscopist on a subsequent day—and even worse—be forced to take a second colon prep in order to have the polyps removed. This is not only an unacceptable inconvenience for Medicare beneficiaries, but will likely result in many patients refusing to perform the second prep and not getting their pre-cancerous polyps removed.
Because of this, VC should be allowed only in an integrated program, whereby VC results are available immediately following the test and same-day therapeutic colonoscopy is definitively made available to all patients with significant polyps. Such comprehensive programs allow for all of the benefits of VC (easier, safer, no sedation, and less expensive) while overcoming the major deficit (lack of therapeutic option).
Furthermore, these comprehensive programs allow for a progressive "episode-of-care" reimbursement strategy, i.e. a single bundled reimbursement for the entire screening process: VC for all, followed by same-day, same-prep therapeutic colonoscopy in those with significant polyps. I understand that CMS is moving in the direction of episode-of-care reimbursement strategies.
In summary, I urge CMS to help save lives by covering VC in the Medicare program, but to do so in the only way that make sense for patients: within a comprehensive screening program that allows for same-day, same-prep therapeutic colonoscopy, and a bundled, episode-of-care reimbursement
Thank you for your consideration.
"Incidence of Colonic Perforation at CT Colonography: Review of Existing Data and Implications for Screening of Asymptomatic Adults", Perry J. Pickhardt, MD, 2006; 239: 313-31
Dear Dr. Phurrough:
Thank you for the opportunity to comment on the Centers for Medicare and Medicaid Services' (CMS's) call for a national coverage analysis on Screening Computer Tomography Colonography (CTC) for Colorectal Cancer (CAG-00396N). America's Health Insurance Plans (AHIP) is the national association representing nearly 1,300 health insurance plans providing coverage to more than 200 million Americans. We are pleased to submit these comments on behalf of our members.
General Comments
However, there are several caveats to beginning a national coverage analysis immediately. First, results from one important multi-institutional trial, the ACRIN study, have been submitted for publication but are not currently available in the peer-reviewed literature. Second, the U.S. Preventive Services Task Force is in the final stages of making new recommendations on colorectal cancer screening, and CMS may be well served in waiting for their evidence analysis and opinion prior to commencing its own process. And third, studies are underway on a version of CTC that does not require a cathartic bowel preparation. Should these studies demonstrate comparable diagnostic performance, the patient acceptability of a "prepless" CTC may weigh importantly on determinations of its net health benefit, both for individuals, and for the population.
Should the decision be taken to move forward on a national coverage analysis, AHIP urges CMS to follow its prior precedent and include the results of decision analytic modeling as a basis for evaluating both the clinical effectiveness and cost-effectiveness of any new screening strategy for colorectal cancer. In 2003, the National Coverage Determination (NCD) for Screening Immunoassay Fecal-Occult Blood Test (CAG-00180N) made it clear that cost-effectiveness was a core element of the approach to evaluating a screening strategy, and AHIP strongly supports this position. Results of decision analytic modeling should provide CMS with valuable insight into clinical health outcomes. In addition, this modeling will serve as a useful approach to informing decisions on a reimbursement level for a new test that would reflect a reasonable valuation of any marginal net health benefit in comparison to existing alternatives.
In searching for evidence on CTC, CMS should be aware of a prior systematic review of clinical effectiveness by the California Technology Assessment Forum (www.ctaf.org), and a January 2008 systematic review of the comparative clinical effectiveness and cost-effectiveness of CTC performed by the Institute for Clinical and Economic Review (ICER) at Massachusetts General Hospital and Harvard Medical School (www.icer-review.org). The Blue Cross Blue Shield Technology Evaluation Center (TEC) has an evaluation of the clinical effectiveness of CTC in process that will be forthcoming later this year.
Impact of incidental extracolonic findings. A controversial feature of CTC is its concurrent ability to image and to detect abnormalities in extracolonic abdominal tissues. Particularly among otherwise healthy adults undergoing screening examination, incidental lesions present both a clinical and policy challenge. The potential clinical benefit of early detection of some significant lesions needs to be weighed against the overall likelihood that detection of such lesions will not prove clinically valuable and instead will engender unnecessary costs and risks that come with further investigation. A full review of the literature on this topic is available within the ICER final appraisal document.
Future Research Recommendations If CMS determines that the evidence is premature for coverage, AHIP recommends that the specific identified evidence gaps be used to frame a justification for the type of study design that will best address several uncertainties. The ICER review identified several key areas of remaining uncertainty and recommended the following research agenda:
1) What is the impact on population screening rates of making CT colonography available?
A key uncertainty is whether CTC availability would increase population screening rates or would largely shift screening from colonoscopy or other methods to CTC. Several different study designs could be envisioned to address this question, including cluster randomized trials and before-after analyses of defined populations such as a health plan cohort. Both studies would be better performed in a health system where all patient screening can be evaluated over a several-year period, but a large and relatively cohesive health plan cohort, such as that within Kaiser Foundation Health Plans, or more broadly across the HMO Research Network, would provide very useful information.
2) What is the impact on cancer rates of CTC management of medium-sized polyps vs. traditional management with colonoscopy?
Although this is an area of uncertainty, a randomized trial of CTC screening vs. colonoscopy seems impractical. It is unclear whether patients in a large trial would accept randomization, and during the necessary 10-15 year follow-up it is extremely likely that both CTC and colonoscopy will change significantly enough that data will be uninterpretable.
3) What is the impact of extracolonic findings?
It should be feasible to launch studies of patients receiving CTC that will document more precisely the prevalence of extracolonic findings and ascertain their clinical impact and the costs associated with their follow-up. Such studies could potentially be done through passive retrospective claims database evaluation but would be better conducted as prospective cohort studies or patient registries.
4) What is the natural history of diminutive and medium-sized polyps?
Much of the current clinical consensus regarding the management of polyps 1-9mm is based on limited data of the natural history of these polyps. Some CTC advocates point to three fairly old and small colonoscopy studies that left polyps in place as providing evidence that many, if not most, diminutive polyps undergo regression. In these studies, some of the polyps were smaller at follow-up, some were unchanged, and some had grown. In one study, some were not seen at follow-up. A large, prospective study of patients undergoing either CTC or colonoscopy would help address the important uncertainty in this area. If there is substantial regression of polyps, then polypectomy with colonoscopy may be overzealous and the benefits of CTC might appear more substantial.
Colorectal cancer is the second leading cause of cancer death in the United States, with over 130,000 new cases diagnosed each year. There are several other accepted methods for screening for colorectal cancer, and AHIP believes that the decision to add another option merits a national coverage analysis that takes the full range of effects on health and on the Medicare system into consideration. Thank you for the opportunity to comment on this important issue.
[PHI redacted] I strongly feel that it must be approved as a screening tool. It is non-invasive and has proven to be as sensetive as optical in detecting potentially cancerous polyps. It far exceeds the other "screening" options and is cost effective. CTC should be one of the patients'' options. Thank you for your attention. Bill Bond
I do not believe that CTC screening for colon cancer is ready for widespread application. Although some of the studies show good results, there is a great deal of inconsistency in the sensitivity of this test in detecting colon lesions when all studies are considered. In addition, the issue of radiation exposure over a lifetime of screening has yet to be satisfactorily addressed.
The fact that CMS has initiated a national coverage analysis (NCA) for CT colonography (CTC) screening indicates that there is a growing realization of the value of this test as a screening modality for CRC and I wholeheartedly endorse its approval. In a country in which adherence rates for screening of the 2nd leading cause of (preventable) cancer death it is clear that additional, valid options are needed. As one of the larget CTC centers in the country, we have proven that an integrated model, with gastroenterology and radiology working in concert can result in greater penetration of CRC screening and make a real difference in our patients'' lives. We have seen our CRC screening adherence move beyond 70% of our empanelled patients and our CRC screening procedures increase by 90% over the 4 years that we have been refining the process. Performance characteristics of CTC in our institution is equivalent to optical colonoscopy to a polyp size of 6 mm. The concern about diminutive polyps is a real and valid one but clinicians and policy makers must keep the big picture of other screening alternatives in mind when considering these issues surrounding new tests. CTC should not be thought of as a colonoscopy replacement, but rather an alternative test that intuitively is superior to other non-colonoscopic CRC screening tests commonly practiced (FOBT, FS, ACBE). Moreover, this test, widely perceived as less invasive and more convenient, is bringing in people who would otherwise avoid screening for accurate, whole-colon evaluations and saving lives through pushing those who need polypectomy to colonoscopy. The motivation here should remain optimizing adherence with CRC screening and if this additional test will help in that goal then approval be pursued. Issues remain with regards to training and clinical outcome algorithms but CTC in its current form deployable and feasible as a CRC screening test with appropriate forethought and responsible implementation.
According to an overview on colorectal cancer screening found on the CMS website: "Medicare has covered colorectal cancer screening tests and procedures since 1998, but use of this benefit has been low. Medicare claims from 1998 - 2004 indicate that only about 52% of beneficiaries have had at least one claim for a colorectal cancer test during this window. There is clearly an opportunity to improve colorectal cancer screening rates in the Medicare population" (http://www.cms.hhs.gov/ColorectalCancerScreening/, retrieved June 11, 2008).
We have shown at University of Wisconsin Hospital and Clinics that when virtual colonoscopy (VC) is offered as a screening tool, we screen twice as many patients as optical colonoscopy (OC) alone. In many cases, we are attracting these patients from a group that might not have ever had colon cancer screening had they not been presented with VC as an option. From our experience of performing over 5,000 screening exams it is easy to see that VC is an accepted option for colorectal cancer screening by both providers and patients and therefore could increase the overall compliance rate with colorectal cancer screening if offered to Medicare patients.
An additional issue is that there does not appear to be enough endoscopists to accommodate the patients that do seek screening in a reasonable amount of time. VC offers a perfect first-line screening tool for our GI partners to refer them the patients that only need therapeutic intervention. This method ultimately allows GI to efficiently use their invasive, more costly services for patients that require polypectomy. As the "baby boomer" generation has mostly surpassed age 50, we are well aware that this population will further put a strain on endoscopy services. As this population continues to age, it would be prudent to have an additional test to meet their screening needs that is as good as OC, if not better.
Gastroenterologists may feel the pressure from the back-log of patients, but CMS may also eventually feel the increasing financial burden to cover these necessary screening tests. VC is considerably less expensive than a regular colonoscopy. Although it is true that a percentage of patients that have VC will require subsequent OC for polypectomy, the overall cost long-term is still less for VC when this is added because most patients are going to have a normal exam. Not to mention the cost that OC generates when they have a complication from perforation, bleeding, or from the sedation. Furthermore, if a patient that would only consider VC as a screening option decides not to get any colon cancer screening because VC is not covered, and that person gets colon cancer, the cost of surgery and chemo, and potentially the cost of their life cannot compare to the potential benefit the VC could have had.
Moreover, barium enema is a reimbursable exam for screening for colorectal cancer. This exam is more invasive and less comfortable for the patient. It is considerably less accurate than VC and could be said to have the same limitations (i.e. if a polyp is identified a subsequent OC would need to be performed for polypectomy).
We are very fortunate to be the only center in the nation for the past four years to have third-party coverage for VC screening. Because of this, we have relevant experience in the application of VC and how we can impact patients'' lives everyday with technology that is as accurate and more sensitive than optical colonoscopy. I have chosen not to submit any published research results as I am sure you have already received several publications to review. Instead I implore you to not only consider the statistics and published results, but also take into consideration the realistic life saving impact VC could have for Medicare or Medicaid patients. The American Cancer Society already recognizes VC as an effective option. If medical providers/payers truly care about the fight to prevent colon cancer, then the time is now to include VC as an option for colon cancer screening so that patients have another effective option to detect this deadly, yet preventable disease.
Holly Casson, RN, BSN University of Wisconsin Hospital and Clinics Clinical Program Coordinator-Virtual Colonoscopy
I strongly urge CMS to add CT colonography (CTC) as a screening option for colorectal cancer. For more than a decade now abundant research has been performed and CT techniques have evolved to the point where CTC, as it is now performed today, has convincingly proven itself as a valid and highly effective screening tool for colorectal neoplasia.
Colon cancer is the 2nd leading cause of cancer deaths in this country. Americans have a 6% risk of developing colon cancer at some point in their lives. The good news is that over 95% of colon cancer deaths are preventable as the vast majority of colon cancers show a slow and indolent pattern of onset. The bad news is that only 40% of eligible patients undergo any form of screening at all with less than 15% undergoing the "gold" standard of traditional colonoscopy. Under these circumstances any new option for screening is better than no screening at all.
Compared to traditional colonoscopy, CT colonography (CTC) is the cheaper, faster, and safer option. With CTC, there is no need for sedation, less manpower is required (no need for an anesthetist or nurse), less technical operator skill required, and examination time is quicker (table time ~ 15 mins). The risk of serious complications such as colonic perforation is also significantly lower with CTC. The risk of perforation is ten times lower than for traditional colonoscopy with a reported perforation rate between 0.02% and 0.04% (Pickhardt, P. J. Radiology 2006;239(2): 313-6.). The risk of radiation exposure with CT colonography is also relatively low with use of currently accepted low-dose techniques resulting in a radiation dose less than that of a double-contrast barium enema (< 5 mSv).
The adenoma-carcinoma sequence accounts for the large majority of colon cancers. The natural history of colon cancers has been well documented and while many adenomas are found in the sub 5 mm size range, the vast majority of these adenomas remain stable or may even regress and are not likely to be clinically significant. Less than 1% of polyps in this size range progress to true malignancy. The few that do increase in size should be picked up on a 5-year follow-up study. There is a clear documented correlation between adenoma size and risk of malignancy raising the valid question of whether diminutive polyps are even worth resecting at all (much less mentioning in a CTC study). (O'Brien MJ et al. The National Polyp Study. Gastroenterol 1990;88:371-379.). When an economic comparison is made between CTC and other forms of colorectal screening (including traditional colonoscopy), CTC focused on detection of polyps greater than 5 mm in size has been shown to be the most cost-effective screening strategy (Pickhardt PJ et. al., Cancer 2007; 109:2213-2221. Arnesen R et. al., Acta Radiologica 2007; 48:259-266.).
Numerous large multi-center randomized clinical trials performed in multiple countries around the globe in both an academic and community medical setting have shown sensitivity and specificity very comparable to that of traditional colonoscopy. These results have been especially convincing in the last few years with the use of modern multi-detector CT scanners and the increasing use of oral fecal/fluid tagging agents. These results seem to hold true not just in the hands of a few "expert" CTC readers, but across a wide variety of practice settings. (ACRIN National CT Colonography Trial, Munich Trial, IMPACT, SIGGAR, French Multi-center Trial, and others). It is interesting to note that Pickhardt''s New England Journal of Medicine study even suggested that CTC showed better sensitivity than traditional colonoscopy in the detection of larger polyps (using segmental unblinding of colonoscopy combined with CTC results as the gold standard).
CTC has also shown equal efficacy compared to traditional colonoscopy in the detection of advanced neoplasia when compared to traditional colonoscopy (Kim DH, Pickhardt PJ, Taylor AJ, et al. N Engl J Med 2007; 357:1403-1412.). A recent clinical trial involving over 6200 patients demonstrated that primary CTC for screening sent less than 8% of patients on to traditional colonoscopy with resection of less than 25% the number of polyps of traditional colonoscopy, yet resulting in an equivalent yield in the number of patients with advanced neoplasia. As for patient tolerance of the procedure itself, colonic distention in CTC is generally well tolerated without the use of sedation (which carries a real and significant concomitant risk). Unlike after a traditional colonoscopy, the unsedated CTC patient is able to return to work immediately following the procedure resulting in much less loss of productivity. Most surveys of patients that have had both traditional colonoscopy and CT colonography have also shown a greater patient preference for CT colonography with most patients preferring continued CTC surveillance over traditional colonoscopicsurveillance.
When a viable alternative cancer screening option such as CTC has been shown to be equally or nearly equally as sensitive as the currently accepted "gold" standard, as efficacious in the detection of clinically significant polyps, not to mention safer, faster, cheaper, and better tolerated, then there should be no question that CT colonography deserves its place amongst the covered colon cancer screening options for Medicare patients. The U.S. Multi Society Task Force on Colorectal Cancer thinks so, the American College of Radiology thinks so, and the American Cancer Society thinks so as well.
i think it would be nice for this procedure to be covered by cms. even though it is seen as another layer( diagnostic only) of testing but better than a barium enema some would benefit from its inclusion, may be replace Barium enema as a screening option.
CTC should not be used as a standard screening test for colorectal cancer. This is an appropriate test for patients who have failed conventional colonoscopy, but should not be widely applied to the general public.
Though this test does detect larger polyps it is poor for small and medium sized lesions. The argument from the proponents of this test is that small and medium sized lesions don''t really matter, when in fact almost ALL GI physicians have removed cancers that are small in size. The test would clearly lead to over-utilization of CT scanning and increase the number of colonoscopies as well. Radiologists in the community have a strong tendency to "overcall" lesions on these scans (the number of small, benign renal cysts is just one example). The proponents of CTC advocate essentially lying about findings and not even mentioning that they saw a lesion on the scan if it doesn''t meet a certain size in order to try and prevent over-utilization and too many colonoscopies after CTC. This will fail as soon as 1 person in the community setting is sued for missing a cancer.
In the end analysis- this test is not as accurate, promotes over-utilization of resources, offers no therapeutic benefits, and has had the data surrounding the test and the criteria for reading the test manipulated so heavily as to make it appear reasonable.
CTC does have a role in limited cases where patients are unable to have colonoscopy or have for some reason failed colonoscopy.
Besides limiting the chance of bowel perforation, CTC is more thorough, hands down. There is an image that can be reviewed multiple times that is not subject to Dr skill with scope. There is not sedation required that can put the patient at higher risk and takes how many less staff to prep and get the info? What about 5 or 6 less paid professionals? As a patient and healthcare professional, the biggest issue should be about getting the most information with an exam with the least stress or risk to the patient. I see CTC as my professional and personal choice over colonoscopy.
I have interpreted over 150 virtual colonoscopy cases and have discovered many clinically significant polyps in asymptomatic patients that have undergone incomplete optical colonoscopy. I have also had cases where incomplete optical colonoscopy was followed by VC, with VC identifying small polyps. Repeat optical colonoscopy in these patients failed to identify the polyps, but where again identified as true positive findings on blinded followup VC. I have many patients who would like to avoid the risk of and/or have fear of anesthesia associated with optical colonoscopy and would like the option of virtual colonosocpy, but cannot afford it. I argue that they cannot NOT afford to be screened for colon cancer!
I fully support virtual colonoscopy. Virtual Colonoscopy has been clinically proven to be as effective as optical colonoscopy, the current gold standard, in several major studies. Optical colonoscopy is only considered the "gold standard" because an equal or better test has not existed until now.
Virtual colonoscopy, being minimally invasive, drastically improves the chances that the majority of the recommended screening population (i.e. 50 years and older) will actually be screened for cancer, unlike the current estimates between 15-40% currently being screened with other procedures. Since virtual colonoscopy has been proven to be as effective, I believe Medicare and Medicaid patients should have the opportunity to use virtual colonoscopy as a screening choice.
I base my opinion on personal experience and the following list of articles which I have read:
American Gastroenterological Association"AGA Supports New Guidelines Favoring Tests That Prevent Colorectal Cancer ", March 5, 2008
Alimentary Pharmacology & Therapeutics"Virtual vs. optical colonoscopy in symptomatic gastroenterology out-patients: the case for virtual imaging followed by targeted diagnostic or therapeutic colonoscopy", M.Bose, J.Bell, L.Jackson, P.Casey, J.Saunders, O.Epstein Volume 26 Issue 5 Page 727-736, September 2007
American Cancer Society"Prevention the Focus of New Colon Cancer Screening Guidelines", Article date: 2008/03/05
American Journal of Roentgenology" Primary 2D Versus Primary 3D Polyp Detection at Screening CT Colonography",Perry J. Pickhardt, Andrew D. Lee, Andrew J. Taylor, Steven J. Michel, Thomas C. Winter, Anthony Shadid, Ryan J. Meiners, Peter J. Chase, J. Louis Hinshaw, John G. Williams, Tyler M. Prout, S. Hamid Husain, David H. Kim, 189, December 2007
Annals of Internal Medicine"Location of Adenomas Missed by Optical Colonoscopy", Perry J. Pickhardt, MD; Pamela A. Nugent, MD; Pauline A. Mysliweic, MD, MPH; J. Richard Choi, ScD, MD; and William R. Schnindler, DO, September 7, 2004 | Volume 141 Issue 5| Pages 352-359
Archives of Internal Medicine "Computed Tomographic Colonography to Screen for Colorectal Cancer, Extracolonic Cancer, and Aortic Aneurysm", Model Simulation With Cost-effectiveness AnalysisCesare Hassan, MD; Perry Pickhardt, MD; Andrea Laghi, MD; Daniel Kim, MD; Angelo Zullo, MD; Franco Iafrate, MD; Lorenzo Di Giulio, MD; Sergio Morini, MD Arch Intern Med. 2008;168(7):696-705.
Radiology"Screening for Colorectal Neoplasia with CT Colongraphy: Initial Experience from the 1st Year of Coverage by Third-Party Payers", Perry J. Pickhardt, MD, Andrew J. Taylor, MD, David H. Kim, MD, Mark Reicheldferfer, MD, Deepak V. Gopal, MD, and Patrick R. Pfau, MD, 2006. 0:2412052007
I hope you take all of this into consideration when making your final decision. I believe you will reach the same conclusion:
Virtual colonoscopy is a safe, noninvasive, powerful, sensitive, and specific alternative to optical colonoscopy that should and must be made available to the general public as an effective screening method for colon cancer. Virtual colonoscopy has the power to become the NEW gold standard. It is certainly more effective than some currently reimbursed procedures such as flexible sigmoidoscopy, fecal blood occult screening and barium enemas.
Ronald J. Costanzo, MDDepartment of RadiologyDoylestown HospitalDoylestown, PA
I work at NNMC and have been scheduling patients for and assisting in completion of virtual colonoscopies since Oct/04 - our patients like having a 20 minute appointment that clears them for 5 years. If they are on anticoaugulation, it does not need to be stopped. Patients who are too ill for sedation can safely have VC(s), no driver/escort is needed. And it is nice to be able to give healthy low risk screening patients a choice in which screening modality is used.
I am strongly in favor of CMS extending coverage to CTC for the simplest of reasons; all comments from patients or family members of patients were very positive in their opinion of CTC. Optical colonoscopy has been the gold standard for at least two decades and its practitioners have been uniformly unsuccessful in increasing compliance with CC screening guidelines. CTC clearly has the potential to reach the 40 million Americans who are eligible for CC screening but have not come forward for the many reasons put forth in these commentaries. As the previous Medical Director for EZEM, I have spent the past 20 years in CC screening and detection and have intimate knowledge of the double contrast barium enema, optical colonoscopy and CTC. It is clear to all that asymptomatic individuals between the ages of 50 and 75 who have not as yet been screened are clamoring for CTC to become part of their healthcare benefit. You (CMS) can make it so.
May 28, 2008
Ref: CAG-00396N
Dear Centers for Medicare & Medicaid Services (CMS):
I fully support virtual colonoscopy screening for colon cancer. According to my research and readings, virtual colonoscopy has been clinically proven to be as effective as optical colonoscopy, the current gold standard, in several major studies. Because virtual colonoscopy is less invasive, it drastically improves the chances that the majority of the recommended screening population (50 yrs +), will actually be screened for colon cancer, unlike the current estimates between 15% - 40% being screened with other procedures.
Virtual colonoscopy has a very high degree of sensitivity. Since virtual colonoscopy has been proven to be as effective, I believe patients should have the opportunity to use virtual colonoscopy as a screening choice. I believe that patients are more willing to lie in a CT scanner for a scan, there is no sedation required, they can drive themselves home, and the scan takes a few minutes (especially in the fast multi slice CT scanners). 70% to 75% of Americans are not getting screened for colon cancer because most do not like the invasive optical colonoscopy. If they get screened with virtual colonoscopy, just think of how many cases of colon cancer can be found early and how many lives can be saved.
The American Cancer Society, backed by American College of Radiology and American Gastroenterology Association has endorsed this exam as a front line exam for colon cancer screening. Some of the currently reimbursed procedures are flexible sigmoidoscopy, fecal blood occult screening, and of course the long time test of the barium enema. The virtual colonoscopy should be reimbursed as well.
It is my hope that CMS will also see this exquisite tool that is sitting in the palm of your hands, only waiting for reimbursement to be approved to start saving more lives.
Thank you for your consideration and your time in reading my email. Below is a list of some of the studies that I have based my opinion on. The list is as follows:
"Computed Tomographic Virtual Colonsocopy to Screen for Colorectal neoplasia in Asymptomatic Adults", Perry J. Pickhardt, M.D., J. Richard Choi, Sc.D., M.D., Inku Hwang, M.D., James A. Butler, M.D., Michael L. Puckett, M.D., Hans A. Hildebrandt, M.D., Roy K. Wong, M.D., Pamela A. Nugent, M.D., Pauline A. Mysliwiec, M.D., M.P.H., and William R. Schindler, D.O., December 2003 issue (Vol. 349, No. 23)
Archives of Internal Medicine "Computed Tomographic Colonography to Screen for Colorectal Cancer, Extracolonic Cancer, and Aortic Aneurysm", Model Simulation With Cost- effectiveness Analysis Cesare Hassan, MD; Perry Pickhardt, MD; Andrea Laghi, MD; Daniel Kim, MD; Angelo Zullo, MD; Franco Iafrate, MD; Lorenzo Di Giulio, MD; Sergio Morini, MD Arch Intern Med. 2008;168(7):696-705.
Thank You.
The cost effectiveness of adopting CTC as a Colorectal Ca screening tool is an important consideration when compared to the higher costs of optical colonoscopy. CTC has an increased patient acceptance that will in the long term lead to more screenings and eventual treatment of CA that would have otherwise not been diagnosed. The use of CAD and advanced fecal tagging technology will provide more diagnostic confidence to the radiologists and will improve the overall specificity and sensitivity of CTC.


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Jump aboard Dreamweaver CS6 and learn the latest new features in Adobe's flagship web layout application. First, you'll master the Dreamweaver interface, defining sites, and handling files. Then, it's on to building a web layout from complete scratch; you'll learn how to insert text, manage graphics, insert Smart Objects, and format tables. Then, discover powerful new CSS Transition effects, as well as the new Fluid Grid Layout options. If you want to quickly get up and running with Dreamweaver CS 6, then this VTC course by author and expert Geoff Blake is exactly what you need. To begin learning today, simply click on the movie links.
A Look at the Dreamweaver Interface
(06:18) TExploring Additional Panels pt. 1
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(05:52) TUnderstanding the CSS Box Model
(03:50) TCentering the Layout and Previewing
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(04:28) TAdjusting the Content Container pt. 1
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(04:33) TCreating Numbered and Bulleted Lists
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Making a compiler-independent project gives the developer a significant amount of flexibility. The risk associated with compiler dependence is diminished and the performance of compilers can be examined and compared side-by-side. Changes to one line of code in a header file will propagate throughout the project, which can decrease debugging time. The overall effort to port an existing project or to create a compiler-independent project is minimal. The benefits and ease of generating compiler-independent code for microcontrollers makes this approach something that any developer should consider.
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PHOTOS: Lightning strike blows up transformer on Fifth Avenue South
A surge from a lightning strike blew up a transformer behind the Colonnade on 5th Wednesday afternoon, sending a fireball into the building's breezeway and shutting down several businesses for the day.
The lightning struck a pole hundreds of feet behind the Colonnade, 600 Fifth Avenue South, during an intense storm around 3:15 p.m., Naples Fire Chief Steve McInerny said. Naples firefighters were on scene by 3:19 p.m.
"The lightning surge traveled underground to this three-phase transformer box, and it blew this box apart," McInerny said. "It exploded from the inside out."
The explosion shook the building, and was heard about five blocks away, McInerny said. Firefighters were faced with heavy smoke and flames.
A fireball blasted through the Colonnade's breezeway, but because of the rain, nobody was in the breezeway at the time.
"Had the storm been approaching or just departing, and there wasn't associated rain, somebody could have been seriously injured," McInerny said.
Firefighters had to wait for a Florida Power and Light worker to arrive at the scene to turn off the power before they were able to hose the box down with foam. Eight Naples firefighters were joined on scene by Naples police officers.
Damage was estimated at $10,000, McInerny said.
Businesses in the Colonnade, including Chico's and Huntington Bank, were closed for the day while an FPL official worked to restore power.
"It looks like a bomb exploded in this box," McInerny said.
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Book your room at Grand Mirage Resort & Thalasso Bali
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Max Occupancy: 3 guests (up to 2 children, 2 infants)4.5-star beach resort with a full-service spa
With a stay at Grand Mirage Resort & Thalasso Bali in Nusa Dua (Tanjung Benoa), you'll be close to Turtle Island and Nusa Dua Beach.
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Make yourself at home in one of the 301 air-conditioned rooms featuring minibars and LCD televisions. Rooms have private furnished balconies. Complimentary wireless Internet access keeps you connected, and satellite programming is available for your entertainment. Private bathrooms have deep soaking bathtubs and rainfall showerheads.
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Enjoy a meal at one of the resort's dining establishments, which include 4 restaurants and a coffee shop/café. From your room, you can also access 24-hour room service. Thirsty? Quench your thirst at a bar/lounge, a beach bar, or a poolside bar.
Featured amenities include a business center, a computer station, and complimentary newspapers in the lobby. Planning an event in Nusa Dua? This resort has 1100 square feet (99 square meters) of space consisting of a conference center and a meeting room. Free valet parking is available onsite.
Information missing or incorrect? Tell us!Hotel Amenities
All-Inclusive Details
All-inclusive room rates at Grand Mirage Resort & Thalasso Bali are available. These rates are higher because they include onsite food and beverages in the room rate (some restrictions may apply).
Hotel Amenities
Some rates at Grand Mirage Resort & Thalasso Bali are all-inclusive. These rates include onsite meals and beverages, and may include taxes and gratuities. Additional charges may apply for meals at some restaurants, special dinners and dishes, certain beverages, and other amenities.
Hit the beach and work on your tan in the sun loungers (chaise longues) or relax in the shade with cabanas (surcharge) and umbrellas. Pamper yourself with a treatment at the full-service spa and enjoy amenities at Grand Mirage Resort & Thalasso Bali like a complimentary children's club and an outdoor pool.
Dining is available at one of the resort's 4 restaurants and guests can grab coffee at the coffee shop/café. The property also has a snack bar/deli. Guests can unwind with a drink at one of the resort's bars, which include a beach bar, a swim-up bar, and a poolside bar. A computer station is located on site and high-speed wireless Internet access is complimentary. This luxury resort also offers a children's pool, outdoor tennis courts, and a fitness center. Guests can use the outdoor pool at a partner hotel. Onsite valet parking is complimentary.
Grand Mirage Resort & Thalasso Bali has designated areas for smoking.
- Beach umbrellas
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- ATM/banking
- 24-hour front desk
- Business center
- Fitness facilities
- Arcade/game room
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- Designated smoking areas (fines apply)
- Designated smoking areas
- Free area shuttle
- One meeting room
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- Laundry facilities
- Library
- Total number of rooms - 301
- Number of floors - 4
- Free valet parking
- Poolside bar
- Number of restaurants - 4
- Conference space size (meters) - 99
- Bar/lounge
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- Coffee/tea in lobby
- Coffee shop or café
- Free newspapers in lobby
- Dry cleaning/laundry service
- Elevator/lift
- Full-service spa
- Hair salon
- Beach/pool umbrellas
- Billiards or pool table
- Grocery/convenience store
- Tours/ticket assistance
- Spa treatment room(s)
- Multilingual staff
- Garden
- Picnic area
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- Safe-deposit box at front desk
- Conference center
- Outdoor tennis courts 2
- Snack bar/deli
- Conference space size (feet) - 1100
- Year Built 1993
- Tennis on site
- Shopping on site
- Number of buildings/towers - 1
- Spa services on site
- Children's pool
- Outdoor pool
- Swim-up bar
- Television in lobby
- Wedding services
Available in all rooms: Free WiFi
Available in some public areas: Free WiFi
Free valet parking
Room Amenities
- Free WiFi
- Free cribs/infant beds
- Premium TV channels
- Air conditioning
- Phone
- Minibar
- Coffee/tea maker
- Hair dryer
- Deep soaking bathtub
- Rainfall showerhead
- Bidet
- Free bottled water
- Access via exterior corridors
- Iron/ironing board
- In-room safe
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- Connecting/adjoining rooms available
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- Desk
- Rollaway/extra beds available
- Blackout drapes/curtains
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- Down comforter
Where to Eat
Grand Cafe - This poolside buffet restaurant specializes in international cuisine and serves breakfast, lunch, dinner, and light fare. Guests can enjoy drinks at the bar. A children's menu is available. Happy hour is offered. Open 24 hours.
La Cascata - This fine-dining restaurant specializes in Italian cuisine and serves dinner only. Guests can enjoy drinks at the bar. Reservations are required. Open select days.
Jukung Grill - This beach restaurant specializes in seafood and serves lunch and dinner. Guests can order drinks at the bar and enjoy alfresco dining (weather permitting).
Coconut Pool Bar - This poolside bar serves light fare only.
Panorama Lounge - Overlooking the ocean, this lobby lounge specializes in international cuisine and serves light fare only.
Late night fare is available from 24-hour room service.
Nearby Things to Do
Outdoor tennis courts and complimentary bicycles are featured at the resort. An outdoor pool and a children's pool are on site. Other recreational amenities include a fitness center.
The recreational activities listed below are available either on site or nearby; fees may apply.
- Free bicycles on site
- Golfing nearby
- Surfing/boogie boarding nearby
- Rafting nearby
- Scooter/moped rentals nearby
- Hiking/biking trails nearby
- Aerobics on site
- Basketball on site
- Bicycle rentals on site
- Fishing on site
- Kayaking on site
- Motor boating on site
- Parasailing on site
- Playground on site
- Rowing or canoeing on site
- Sailing on site
- Scuba diving on site
- Snorkeling on site
- Tennis lessons on site
- Volleyball on site
- Windsurfing on site
- Yoga classes/instruction on site
- Beach volleyball on site
- Beach yoga on site
- Boat tours on site
- Ecotours nearby
- Golf lessons available nearby
Spa Services
Thalasso Bali has 22 treatment rooms including rooms for couples and outdoor treatment areas. Massages are available on the beach and in the spa; other services include facials, body wraps, and body scrubs. A variety of treatment therapies are provided, including aromatherapy, Ayurvedic, and hydrotherapy. The spa is equipped with hot springs/mineral springs and a sauna.
Children under 12 years old are not allowed in the spa without adult supervision.
- Number of treatment rooms 22
- Outdoor treatment areas
- Couples treatment rooms
- Massages on beach
- Manicures and pedicures
- Body wraps
- Body scrubs
- Aromatherapy treatments
- Thalassotherapy treatments
- Hydrotherapy treatments
- Ayurvedic treatments
- Sauna in spa
- Hot springs/mineral springs in spa
- Massages
- Body treatments
- Facial treatments
To make requests for specific accessibility needs, complete the "Special or Accessibility Requests" section of "Trip Preferences" when you book your hotel.
- Accessible path of travel
Hotel Policies
Check-in time starts at 2 PM
Check-out time is noon
Payment types
You need to know
Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
- New Year's Eve gala dinner fee
We should mention
A fee for a mandatory New Year's Eve gala dinner is included in the total price displayed for stays on 31 December. Children 5 years old and younger stay free when occupying the parent or guardian's room, using existing bedding. The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation.


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On Friday night, Bruce Jenner made history by announcing on 20/20 that he believes he is and always has been a woman.Here are the biggest takeaway quotes from the two-hour special.(A quick note:...
Suicide Squad director David Ayer has released the first official photo of star Jared Leto in...
Kim Kardashian West and her family will be in the same place as the rest of us Friday night:...
San Francisco, a city with no shortage of status symbols, has just gained another: the 415 area code. Like New York's 212 before it, phone companies are mixing a new, dare-we-say ugly area code, 628, in for new numbers. But there's no need to panic.
A little bit of your childhood – or perhaps your child's past – died earlier this week.
Patrick "Dr. McDreamy" Dempsey got emotional discussing the decade he spent on
You always remember your first, right? Not Zendaya!We played a round of "What's Shakin'?"...
David Harold Thomas, 71 of Elkview passed away April 22, 2015 at Charleston Memorial Hospital following a long illness.
Albert Joseph Witschy, 71, of Ravenswood, WV, passed away on April 21, 2015, in Parkersburg, WV.
Franklin David Richardson, 74, of Vinton, OH, passed away April 21, 2015 in Riverside Methodist Hospital following an extended illness.
Hey everyone!Thanks for all your messages!So, yeah... where do I begin? It was a fluke accident. I was practicing for the 10th anniversary special Monday night after the show. I was dancing with Amy Purdy, Maria Menounos, Amber...
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The Penguins selected Mario Lemieux with their pick, added Doug Bodger with the selection they got from the Jets and claimed St. Catharines, Ontario native Roger Belanger with the pick they got from Philadelphia. Amazingly, all three youngsters played in the NHL the following year, with Lemieux recording a 100-point season and capturing the rookie of the year and Bodger logging 65 games on the Penguins blueline. Belanger, a six-foot center, played 44 games for the Penguins, notching three goals and five assists.
The following season, Belanger couldn't crack the improving Penguins roster and was assigned to the Penguins American Hockey League affiliate. It would prove to be the last season of his career that wasn't decimated by injuries. While Belanger played 69 games that year, he dropped to just 37 the following year and just seven in his final year of pro hockey before the constant injuries forced him out of the game.


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Hear from IT leaders and industry experts in more than 100 sessions at the leading business technology event.
Managing Director, Cloud Strategy Partners
David Bernstein is the Managing director of Cloud Strategy Partners. Most recently, has was VP/GM in Cisco's Office of the CTO. His team ran Cisco's Cloud Lab, was responsible for Cisco's University, Research, and Industry activities in Cloud Computing. He headed development for Cisco's Cloud Security, Interoperability and Standards initiatives. David's experience includes executive positions in AT&T, Siebel Systems, Pluris, InterTrust, and Santa Cruz Operation. His extensive consulting experience along with his recent leadership and expertise in Cloud Computing has led to the formation of Cloud Strategy Partners, LLC. David holds nearly a dozen patents in software and communications, publishes research regularly in IEEE, ACM, and IARIA conferences, and is a member of the IEEE Advanced Technology Executive Forum. He was a key author/contributor to many industry standards such as OpenSOA.org, OASIS SCA, WS-I, JCP/J2EE, and IEEE POSIX. David holds degrees in Physics and Mathematics from University of California where he was awarded the UC Regents Scholar designation for his work for the Office of Naval Research.


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Imaging tool may aid nanoelectronics by screening tiny tubes
November 17, 2010
WEST LAFAYETTE, Ind. - Researchers have demonstrated a new imaging tool for rapidly screening structures called single-wall carbon nanotubes, possibly hastening their use in creating a new class of computers and electronics that are faster and consume less power than today's.
The semiconducting nanostructures might be used to revolutionize electronics by replacing conventional silicon components and circuits. However, one obstacle in their application is that metallic versions form unavoidably during the manufacturing process, contaminating the semiconducting nanotubes.
Now researchers have discovered that an advanced imaging technology could solve this problem, said Ji-Xin Cheng, an associate professor of biomedical engineering and chemistry at Purdue University.
"The imaging system uses a pulsing laser to deposit energy into the nanotubes, pumping the nanotubes from a ground state to an excited state," he said. "Then, another laser called a probe senses the excited nanotubes and reveals the contrast between metallic and semiconductor tubes."
The technique, called transient absorption, measures the "metallicity" of the tubes. The detection method might be combined with another laser to zap the unwanted metallic nanotubes as they roll off of the manufacturing line, leaving only the semiconducting tubes.
Findings are detailed in a research paper appearing online this week in the journal Physical Review Letters.
Single-wall nanotubes are formed by rolling up a one-atom-thick layer of graphite called graphene, which could eventually rival silicon as a basis for computer chips. Researchers in Cheng's group, working with nanomaterials for biomedical studies, were puzzled when they noticed the metallic nanoparticles and semiconducting nanowires transmitted and absorbed light differently after being exposed to the pulsing laser.
Then researcher Chen Yang, a Purdue assistant professor of physical chemistry, suggested the method might be used to screen the nanotubes for nanoelectronics.
"When you make nanocircuits, you only want the semiconducting ones, so it's very important to have a method to identify the metallic nanotubes," Yang said.
The paper was written by Purdue physics doctoral student Yookyung Jung; biomedical engineering research scientist Mikhail N. Slipchenko; Chang-Hua Liu, an electrical engineering graduate student at the University of Michigan; Alexander E. Ribbe, manager of the Nanotechnology Group in Purdue's Department of Chemistry; Zhaohui Zhong, an assistant professor of electrical engineering and computer science at Michigan; and Yang and Cheng. The Michigan researchers produced the nanotubes.
Semiconductors such as silicon conduct electricity under some conditions but not others, making them ideal for controlling electrical current in devices such as transistors and diodes.
The nanotubes have a diameter of about 1 nanometer, or roughly the length of 10 hydrogen atoms strung together, making them far too small to be seen with a conventional light microscope.
"They can be seen with an atomic force microscope, but this only tells you the morphology and surface features, not the metallic state of the nanotube," Cheng said.
The transient absorption imaging technique represents the only rapid method for telling the difference between the two types of nanotubes. The technique is "label free," meaning it does not require that the nanotubes be marked with dyes, making it potentially practical for manufacturing, he said.
The researchers performed the technique with nanotubes placed on a glass surface. Future work will focus on performing the imaging when nanotubes are on a silicon surface to determine how well it would work in industrial applications.
"We have begun this work on a silicon substrate, and preliminary results are very good," Cheng said.
Future research also may study how electrons travel inside individual nanotubes.
More Information
Core Facility Spotlight: Biomolecular Screening and Drug Discovery
April 16, 2015
Searching for compounds to produce new or better drugs is like looking for a needle in a haystack, with inefficient screening for identification and characterization of effective new drug compounds directly impacting the cost of drug development (now in excess of $1 billion per drug).
Read Full StoryDimensions of Discovery - Core Facility Spotlight: 7-Tesla MRI
March 3, 2015
Located in the Bindley Bioscience Center, the powerful Bruker 7-Tesla magnetic resonance imaging machine (MRI), is the only one of its kind in Indiana.
Read Full StoryDr. Joseph Irudayaraj, College of Engineering, Research Excellence Award winner
February 18, 2015
Congratulations to Dr. Joseph Irudayaraj, Deputy Director of the Bindley Bioscience Center, for the 2015 College of Engineering, Research Excellence Award.
Read Full Story


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Fleetguard Cummins - Fleetguard Cummins CV50628
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GTO London
In addition to our handcrafted sterling silver cufflinks engineered & hallmarked by the GTO experts, we now have the RFM Collection available. Imported from London, impeccably stitched wallets using the same genuine Italian calf skin leather Ferrari trusts to their GTO, here you will find accessories fit for Ferrari enthusiasts everywhere.
Real Ferrari Metal Volante Three Spoke Steering Wheel Cuffli
$595.00 / Pair


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Escape - Event 02/08/13 - "me So Horny Gang Bang Party" |
[All 19 Events List] |
"me so horny gang bang party" | |
SLS Liaison: free2swap2000 |
Type: Club |
Escape URL: Escape |
Tonight we turn up the heat on a cold february night! Yes this will be one of those fun parties you just don't want to miss! Couples have you ever shared that special pillow talk about what one would be like? Ladies have you ever wanted to just let go and have some wild safe fun? Single guys don't sit at home and dream about what it would be like! Do you have what it takes to step up to the plate and perform when its your turn? We understand that this type of fun is not for everyone and thats o.k. We always encourage you to come down even if you just enjoy watching. Plus we will always have our 8 private rooms open for your own fun. Escape is the one true club in Ohio that is open every wednesday, friday and saturday nights. We don't close down for private parties and special groups, when you want to go out and have fun – we are there for you! Our members don't have to check I web site to see if they can get in or not! Simply come on down before 11:30pm have your membership card and license and your good to go. Not a member yet? Thats ok as well we allow you to register right at the door. Everyone attending must be over 21 and have a driver license. Stop window shopping at the other clubs and come on out to the place where couples and singles actually meet! Membership: $25 for the year Couples: $30 before 9:30 and $40 after Single Male: $40 before 9:30 and $50 after Single Ladies: $ 5 before 9:30 and $10 after 3901 Lakeside Ave East Cleveland Ohio 44114 216-502-6969 |
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15 members are attending this event. | ||
Click CLEVELAND Swingers to find local swingers |
Events listed above are provided for informational purposes only. SwingLifestyle.com does not control the venue or the events themselves, and cannot guarantee that the events will occur on the dates indicated above. Be sure to check with the specific venues for the latest updated information. |


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I wasn't going to write about this. It's a movie I know too well. Matthew Hale, centuries ago, said that "rape ... is an accusation easily to be made and hard to be proved, and harder to be defended by the party accused, tho never so innocent."
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m. 04 NOV 1847 Putnam, Indiana
Family tree▼ Facts and Events
John Webb was born in Trimble County Kentucky. Trimble County is on the Ohio River between Cincinnati and Louisville. John moved to Indiana with his family around the time he was five. Edna's parents must have brought her to Putnam county as an infant if she was born in Kentucky. Putnam County is west of Indianapolis. John and Edna married in 1847, John was 22 and Edna just 17. Image Gallery


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North Carolina's public school leaders want to know how to make teachers happy and how to improve learning environments across the state.
The state Department of Public Instruction is asking teachers to take a survey on their working conditions beginning Monday through April 20. Teachers can access the survey online at http://www.ncteachingconditions.org/.
State school board chairman Bill Harrison said North Carolina was the first state in the country to conduct a statewide survey of educators 10 years ago. Harrison said data from past surveys shows that positive working conditions improve student learning and teacher retention.
Teacher surveys have found that educators believe their biggest needs are time during the work day for planning lessons, adequate facilities and enough resources.
The 2010 teacher working conditions survey got a response rate of nearly 90 percent.
...just like a Commie, you want to call or label anyone who disagrees with your Big Government solutions to everything "sick"!
No I am not sick, Iam sick and tired of spending my tax money on frivlities and letting the school systems deteriorate to a point where the school is just barely managed chaos!
iam also distressed byt he disappearance of all the cats in downtown Newton and other things that seem to be swept under the rug of a more heinous nature and most of all.... I am sick of you!
Other than that I fell pretty good!
Looking at all your posts. backbone, you are a "sick" individual. I hope and assume, your local police department has taged you as "a person of concern." Hope you get some mental help. Does your military and probation supervisors know of your problems?? Should I let them know you need help? I know how and can do that for you.
Might want to look into the behavioarl issues int he middle and high schools. if the teachers feel safe and reasonably free from crime they will consider themselves better off!
In other words identify the little miscreants and get them out of the schools. Guess what< NOT EVERYONE WAS MENT TO GRADAUTE!


text: Andrew Cole of Power and Praise Tabernacle recent honored Andrew Cole for being the student of the month for the Beginner's Class, taught by Linda Robinson. This class, ages 3-6 yrs, have been studying Creation from the book of Genesis. Andrew was top of his class in attendance, class participation, memory verse, and various other categories. He scored extra points for a nativity scene that he planned and built. Andrew, 5 years old, was presented a certificate and a monogrammed Bible by Sunday School Superintendent, Scott Green, and his teacher Linda Robinson. The presentation was made before his family, the congregation and his Pastor, William Knittel.


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Pennsylvania Area Events & Promotions
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I'm a terrible horrible no good very bad MOM Edit*
my kids helped around the houe as i worked went to college i made there dinner when i could in a crock pot or roaster peeled potatoes put them in cold water ready to put on to cook when they were ready to eat took turns vacuming sweeping did ther own laundry cleaned there rooms mopped took care of ttheir own thing when i had the day off or got home early i helped and on week ends when i had the weekend off i cleaned and i did my own laundry and cleaned my own room if ther was a chore they didnt like doing they would trade off with some one else and thing always seemed to get done but if we wanted to just do something like camping for the week end we did it when we had time we would leave the chores for the day and start again the next day as there was always time for fun for them too we had a chore list and that was your chore for the day even i had my stuff i had to do daily too and my kids i was a single mom due to seperation with four children but they were 12 14 16 18 years old when they needed something i made sure they had it as they say we couldnt afford much but we had a roof over our heads ,food love and had good times and that is what mattered and now they all know how to due thing it takes to live all but one has kids of their ownn form 4 to 5 kids and they make them learn how to do this by helping too
I'm a sahm, and my 21 month old knows what to do when I tell her it's time to clean up. She knows where to put her toys and books. She will occasionally put up random toys to get others out in the middle of playing. I plan to nurture this attitude and teach her more skills as she grows. She is learning what we live and even gets in on pushing the vacuum with me.
Quoting mamiL21:
Slaves- slave drivers. Even if your kids say there not scared does not mean there not. You reffered to yourself as a slave driver on reference towards your children cleaning. ????? I disagree but its your household not mine. We are all gods children not a slave he sent to you because your so high and mighty working those 40 + hours a week that's what you think. I was a single mother until my son was 5 I worked more then 40 hours a week at the hospital on my feet but I still came home tired but I cooked and cleaned. What does not kill a grown adult makes that adult that much stronger.
omg. calling them a slave was a joke. seriously... that was pure sarcasm to make fun of people who have a problem with children helping out.
Quoting HoldensMummy:I think she was being sarcastic when she said she was a slave-driver.
To those of you who do it all yourselves, what about chores WITH your children? If you come home from 40 hours of work, and then do all the cooking and cleaning, what are your children doing? My DH is with us while we cook, "helping" where he can. We all do the dishes together, and talk while we do it. Even when we are all doing different tasks in different rooms, we have the music on, and get that "team" feeling going. By "all" I include my husband, because I don't live in the 50s. We are a family team, looking after our home together.
Just curious- please don't take this question as hostile, I mean it genuinely. For those of you who don't have chores for your kids- are you planning to have a "life-session" at some point where you teach them how to cook, do laundry, clean a bathroom etc. before they leave? Or do you feel that they will learn naturally by watching? Or just figure it out when they move? My own Mom didn't have us do any cooking, and I still don't feel as confident in the kitchen as my hubby who shared the cooking duties with his mom after his dad died.
you have an excellent point in your second paragraph. I didn't cook much either growing up and had to mostly learn everything for myself. I even screw up cooking rice!
Quoting andersongirl562:
I asked my 10 year old DS if kids should have chores and help clean the house. His answer was " Sure mom it's our house to we don't want it looking junky! Plus there are five of us and one of you!" lol we bought our own home 2 years ago and they are super proud of it :)
aw what a sweet kid! what a great attitude! he's right. Glad you got a new home. We need a better home and are working on improving ours.
Quoting Anonymous:My mom made me start doing dishes and cleaning when I was 8, which now looking back, I feel is too young. Maybe some stuff was okay for me to be doing, but I could barely reach the faucet and if I did a bad job I'd get yelled at for not doing it correctly, even though she just told me to do it, without really showing me how to do it, you'd think, oh its not that hard to do dishes, but when you don't really know how to clean in the first place, because you've never seen your mom clean because your older brothers did it, and no one showed you what to do, its a little frustrating, especially when in the first place everything you do is incorrect. I also didn't like that when I got older my mom would always tell me I have done nothing my whole life, but since I was 8 I've been cleaning the house while she sat on her ass and watched, and god forbid it wasn't perfect.
When my kid is older, hes 1, I will give him chores, like take out the trash, and clean his room and stuff like that. I wouldn't put all the household responsibilities on him at 8 years old and yell at him like my mom did with us...I hate yelling. As long as you don't yell at your kids, whatevs.lol
I'm sorry you had to go thru that. I'm not as extreme as your mom was and I don't sit all day not doing my part. for sure. so there is a contrast there. The point is teaching your kids to help out, but not to the extreme of being a tyrant either. I'm sure you understand that. :)
Is there a "high five" button somewhere? There should be a high five button. Like isn't strong enough for what I feel for this post.
*nil carborundum illegitimi*


text: Awesome is been about a month now since i have this problem oops something broke. I lost all my 44 outposts. I have been senting messages to developer and all kinds of problem related issue to the forum I can think of. You know what I quit. Even if the problem is fix I aren't going to start all over again.


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Contact: Carol Gregory, firstname.lastname@example.com, 202-675-8759
(Washington, DC) – Amnesty International USA Executive Director Suzanne Nossel responds to reports that earlier today Senator Kelly Ayotte (R-NH) offered an amendment to the National Defense Authorization Act (NDAA) requiring the Obama administration to create another Guantanamo-like prison overseas:
"Senator Ayotte's call for another Guantanamo -- a new human rights free zone -- is irresponsible and unnecessary. Military and intelligence experts repeatedly assert that terrorism suspects are most effectively tried by U.S. federal courts. The Senate should focus its efforts on addressing the detention provisions in the NDAA that must be amended in order to end indefinite detention and support closure of the Guantanamo prison. It is time for the U.S. government to stop using the flawed doctrine of unending 'global war' to justify human rights violations."
Amnesty International is a Nobel Peace Prize-winning grassroots activist organization with more than 3 million supporters, activists and volunteers in more than 150 countries campaigning for human rights worldwide. The organization investigates and exposes abuses, educates and mobilizes the public, and works to protect people wherever justice, freedom, truth and dignity are denied.